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Based on observation, review of policies and procedures and interview it was determined:
1) the post operative room and Respiratory Therapy Suite was not safe and maintained in a state of cleanliness in that the exhaust fans in the clean and dirty linen closets were dirty and/or nonfunctioning.
2) the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair.
3) the facility failed to create and review policies and procedures on a biennial basis for a) Annual scheduled polarity and tension testing; b) Having each emergency receptacle labeled. c) Annual scheduled electrical panel infrared testing.
4) the facility failed to create, review on a biennial basis and implement policies and procedures for a) Installation and testing of an emergency "Stop" switch 10 to 15 feet away from generator and b) Installation and regularly checking battery powered emergency lighting mounted on the generator for emergency and maintenance purposes.
5) the facility failed to ensure the sprinkler heads were maintained to disperse water effectively in the event of a fire.

The failed practices promoted the spread of infection, had the likelihood to not be able to identify hazardous conditions and take steps to minimize the risks to patients and patient care staff, did not ensure the facility was capable of stopping the generator in the event of an emergency, the backup generator was capable at running to meet the facility's electrical demand, and placed the patients at risk of harm from fire. See C0914 and C0938 for details.

Based on observation and interview it was determined the post operative room and Respiratory Therapy Suite was not safe and maintained in a state of cleanliness in that the exhaust fans in the clean and dirty linen closets were dirty and/or nonfunctioning. The failed practice promoted the spread of infection and had the likelihood to affect all patients and staff in the event of an emergency. Findings follow.

A. Observation of Post OP room at 10:15 AM on 6/12/23 showed to have dirty exhaust fans in the clean linen closet.
B. Observation of the Clean linen closet at 10:15 AM on 6/12/2023 showed to have nonfunctioning exhaust fans.
C. Observation of the Dirty linen closet at 10:15 AM on 6/12/2023 showed to have nonfunctioning exhaust fans.
D. Observation of the Clean linen closet at 10:15 AM on 6/12/2023 showed that the clean linen closet wasn't locked
E. The finding were in A-D were verified in an interview with the Head Nurse on 06/12/2023 at 1:21 PM.



Based on observation of the Respiratory Therapy Suite, Sub Sterile Equipment Room, Endoscopy Suite and patient care areas and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practices promoted the spread of infection and had he likelihood to affect all patients, staff and visitors. Findings follow:

A. Observation of the Respiratory Therapy Suite, and Endoscopy Suite on 6/12/2023 from 10:15 am to 11:23 am showed the following:
1) Mold was present on the ceiling tiles.
2) Brown stained and sagging ceiling tiles were present.
3) Cracked floor tiles.
4) Observation of the Respiratory Therapy Suite on 6/12/2023 at 10:46 AM showed to have no locks placed on any electrical panels.

B. Observation of the Sub Sterile Equipment Room on 6/12/2023 from 10:15 am to 11:23 am showed the following:
1) Mold was present on the ceiling tiles.
2) Brown stained and sagging ceiling tiles were present.
3) Cracked floor tiles
4) The walls had chipped and peeling paint.

C. Observation of patient care areas on 6/12/2023 from 10:15 am to 11:23 am showed the following:
1) Mold was present on the ceiling tiles.
2) Brown stained and sagging ceiling tiles were present.
3) The walls had chipped and peeling paint.

D. The finding of A, B, and C were confirmed in an interview with the Maintenance Supervisor on 6/12/2023 at the time of the observations.


Based on observation, review of policies and procedures and interview, it was determined the facility failed to create and review policies and procedures on a biennial basis for:
1) Annual scheduled polarity and tension testing
2) Having each emergency receptacle labeled.
3) Annual scheduled electrical panel infrared testing.

By not creating and reviewing the policies and procedures biennially, the facility had the likelihood to not be able to identify hazardous conditions and take steps to minimize the risks to patients and patient care staff. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of the facility's policy and procedures on 6/12/2023 showed that the facility failed to create and maintain a policy and procedure for scheduling annual Polarity and tension testing and having each emergency receptacle labeled.
B. There was no evidence the facility conducted an annual Polarity and tension testing.
C. Observation of facility on 6/12/2023 at 1:21 P.M. showed the emergency receptacle were not labeled as emergency receptacles.
D. Review of the facility's policy and procedures on 6/12/2023 showed that the facility failed to create and maintain a policy and procedure for conducting annual scheduled electrical Panel and infrared testing.
E. There was no evidence the facility conducted an annual electrical panel and infrared test
F. The findings of A through E were confirmed in an interview with the Maintenance Supervisor on 06/12/2023 at 1:21 PM.


Based on observation, review of policy and procedure and interview, it was determined the facility failed to create, review on a biennial basis and implement policies and procedures for:

1) Installation and testing of an emergency "Stop" switch 10 to 15 feet away from generator.
2) Installation and regularly checking battery powered emergency lighting mounted on the generator for emergency and maintenance purposes.

The failed practice did not ensure the facility was capable of stopping the generator in the event of an emergency and the backup generator was capable at running to meet the facility's electrical demand. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of the facility's policies on 6/12/2023 showed that the facility failed to create a policy regarding installation and testing of an emergency "Stop" switch 10 to 15 feet away from generator. Observation on 6/12/2023 showed there was no evidence of a "Stop" switch 10 to 15 feet away from the generator.
B. Review of the facility's policies on 6/12/2023 showed that the facility failed to create a policy in regards to installation and regularly checking battery powered emergency lighting mounted on the generator for emergency and maintenance purposes.
C. Observation on 6/12/2023 showed there was no evidence of installation and regularly checking battery powered emergency lighting mounted on the generator for emergency and maintenance purposes.
D. The findings of A, B and C were confirmed in an interview with the Maintenance Supervisor on 6/12/2023 at 1:21 PM.






48330

Based on observation, review of policy and procedure, and interview, it was determined the facility's dietary department failed to log the temperature of the refrigerator, refrigerator walk-in, freezer walk-in and chest freezer for 6 (6/1/2023, 6/2/2023, 6/5/2023, 6/6/2023, 6/10/2023 and 6/11/2023) of 12 days (06/01/2023-06/12/2023) in June 2023. The failed practice did not ensure the food was maintained at established temperatures to prevent spoilage and had the likelihood to affect all patients receiving food from the dietary department. Findings follow:

A. Review of the facility's dietary policy titled, "Temperatures, Equipment," showed that the temperature(s) of each piece of cooling and freezing equipment shall be recorded daily, during the following times, opening of the department, during operations, and closing of department.
B. Review of the facility's dietary policy titled,"Temperatures, Equipment," showed temperature documentation sheets were to be reviewed for quality assurance.
C. Review of the Freezer/Refrigerator Quality Control Log on 06/12/2023 showed there was no evidence the temperature of the refrigerator, refrigerator walk-in, and chest freezer were recorded on 6/1/2023, 6/2/2023, 6/5/2023, 6/6/2023, 6/10/2023 and 6/11/2023.
D. The findings of A-C were confirmed with Dietary Manager and Director of Nursing on 6/12/2023 at 1:15 PM.

Based on observation, and interview of facilities sprinkler system it was determined that the facility failed to ensure the sprinkler heads were maintained to disperse water effectively in the event of a fire. The failed practice placed the patients at risk of harm from fire and had the likelihood to affect all patients admitted to the facility. The findings follow:

A. Observation throughout the facility on 6/12/2023 showed that sprinkler heads extended below the ceilings.

B. The findings of A were confirmed in an interview with the Maintenance Supervisor on 6/12/2023 at 1:21 PM

Based on review of EPA'S (Environmental Protection Agency) Ban on Sewering Pharmaceuticals Introductory Fact Sheet, review of Drug Administration Records and interview, it was determined the facility failed to follow acceptable standards of practice in that the facility practice was to dispose of pharmaceutical waste down the sink for five of five (#1, #5, #7, #9 and #11) doses wasted on the Drug Administration Record. By wasting pharmaceuticals down the sink, the facility was not in compliance with the Environmental Protection Agency's Ban on the practice of sewering pharmaceutical waste. This practice had the likelihood to affect all patients treated in the facility. Findings follow:

A. Review of the EPA's Ban on Sewering Pharmaceuticals Introductory Fact Sheet, dated April 2022, showed effective August 21, 2019, EPA prohibited all healthcare facilities from disposing of their hazardous waste pharmaceuticals down the drain (e.g., no flushing or pouring down a sink). This "sewer ban" is in effect at healthcare facilities of all sizes in all states, territories, and Indian country. In addition to the sewer ban, EPA strongly discourages the sewering of any pharmaceutical, with very few exceptions by any type of facility (Sodium Chloride intravenous fluids, Lactated Ringers, etc).
B. Review of Drug Administration Records that covered May 26, 2023, through June 11, 2023, of Morphine 4 mg/ml (milligram/milliliter) showed 5 doses were wasted in that time frame and the following was documented:
1. Dose #11 was administered on 06/01/2023 and the waste record showed "wasted 2 mg in sink";
2. Dose #9 was administered on 06/01/2023 and the waste record showed "wasted 2 mg in sink";
3. Dose #7 was administered on 06/02/2023 and the waste record showed "4 mg wasted in sink";
4. Dose #5 was administered on 06/02/2023 and the waste record showed "2 mg wasted in the sink"; and
5. Dose #1 was administered on 06/11/2023 and the waste record showed "2 mg wasted in the sink".
C. During an interview on 6/13/2023 at 9:25 AM, the Director of Pharmacy verified the practice of wasting medication down the sink and verified the documentation of wasted Morphine down the sink on the Drug Administration Records.

Based on observation, review of manufacturer's recommendation and interview it was determined the facility stored Intravenous (IV) Solutions in a warmer in one of one (Emergency Department) blanket warmer. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that are treated in the Emergency Department. Findings follow:

A. Review of Baxter manufacturer's recommendations, revised May 2019, showed the IV Solutions should have been stored at room temperature, not stored in a blanket warmer.
B. During a tour of the facility on 06/12/2023, from 10:03 AM to 11:03 AM, observation showed a 1000 milliliter bag of 0.9% Sodium Chloride for IV use stored in a blanket warmer at a temperature of 100 degrees Fahrenheit, in the Emergency Department.
C. During an interview on 06/13/23 at 9:15 AM, the Director of Pharmacy verified the findings at B, and stated there should not be fluids stored in the blanket warmer.

Based on clinical record review, policy and procedure review and interview, it was determined the nursing staff failed to provide evidence of the purpose of administering PRN (as needed) medications and failed to provide evidence of the outcome of PRN medications for 6 (#6, #9, and #16 -#19) of 20 (#1 -#20) patients who were given PRN medications. The failed practice did not ensure the medications were administered for the reason ordered and failed to ensure the medication was effective. The failed practice had the likelihood to affect all patients receiving PRN medications. Findings follow:

A. Review of the facility's policy titled, "Administration of Oral Medications," revised 01/2023, showed the PRN medications administered were to have documented effectiveness within one hour.

B. The findings of A were confirmed in an interview with the Director of Nursing (DON) on 06/14/23 at 11:30 AM. During the interview, the DON stated, "The staff is to document follow-up for PRN oral medications within one hour and IV (Intravenous) medications are to with 20 minutes."

C. Review of Patient #6's Medication Administration Record showed the following examples:
1) Demerol 75 mg (milligrams) to be administered IV every 2 hours PRN. Demerol was documented as given on 05/30/23 at 8:30 AM and 9:32 PM, on 05/31/23 at 5:38 AM and on 06/01/23 at 4:30 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
2) Zofran 8 mg to be administered IV every 6 hours PRN. Zofran was documented as given on 05/30/23 at 10:00 AM and 9:48 PM, on 05/31/23 at 9:31 AM and on 06/01/23 at 1:00 AM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
3) Phenergan 25 mg to be administered IM (Intramuscular) every 6 hours PRN. Phenergan was documented as given on 05/30/23 at 9:00 AM and 6:58 PM, and on 05/31/23 at 5:33 AM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.

D. The findings of C were confirmed in an interview with the HIM (Health Information Management) Director on 06/13/22 at 1:40 PM.

E. Review of Patient #9's Medication Administration Record showed the following examples:
1) Zofran 4 mg to be administered IVP once PRN. Zofran was documented as given on 05/10/23 at 11:14 AM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
2) Morphine 2 mg to be administered IVP once PRN. Morphine was documented as given on 05/10/23 at 11:14 AM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
3) Toradol 30 mg to be administered IVP once PRN. Toradol was documented as given on 05/10/23 at 1:32 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
4) Zofran 4 mg to be administered IVP every 4 hours PRN. Zofran was documented as given on 05/10/23 at 7:47 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
5) Morphine 4 mg to be administered IVP every 4 hours PRN. Morphine was documented as given on 05/10/23 at 7:47 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
F. The findings of E were confirmed in an interview with the HIM Director on 06/13/22 at 2:15 PM.


G. Review of Patient #16's Medication Administration Record showed the following examples:
1) Aspirin 325 mg to be administered once. Aspirin was documented as given on 06/11/23 at 4:50 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
2) Tylenol ES (Extra Strength) 1000 mg to be administered once. Tylenol ES was documented as given on 06/11/23 at 8:30 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
H. The findings of G were confirmed in an interview with the Patient Coordinator on 06/14/22 at 2:09 PM.

I. Review of Patient #17's Medication Administration Record showed the following examples:
1) Nitroquick (Nitroglycerin)Tab 0.4 mg to be administered once. Nitroquick was documented as given on 06/01/23 at 3:03 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
2) Aspirin 325 mg to be administered once. Aspirin was documented as given on 06/01/23 at 3:10 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
J. The findings of I were confirmed in an interview with the Patient Coordinator on 06/14/22 at 2:19 PM.

K. Review of Patient #18's Medication Administration Record showed the following examples:
1) Zofran 4 mg to be administered once. Zofran was documented as given on 05/27/23 at 5:03 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
2) Morphine 4 mg to be administered once. Morphine was documented as given on 05/27/23 at 5:03 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
L. The findings of K were confirmed in an interview with the Patient Coordinator on 06/14/22 at 2:29 PM.

M. Review of Patient #19's Medication Administration Record showed the following examples:
1) Zofran 4 mg to be administered once. Zofran was documented as given on 05/23/23 at 3:32 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
2) Morphine 4 mg to be administered once. Morphine was documented as given on 05/23/23 at 3:32 PM. There was no evidence of the purpose for administering the medication and no evidence of the outcome of administering the medication.
N. The findings of M were confirmed in an interview with the Patient Coordinator on 06/14/22 at 2:39 PM.

Based on observation, and interview, it was determined the facility failed to maintain a sanitary environment in that:

1. There were holes in the wall and ceiling in the laundry area.
2. There were water leaks in laundry area.
3. There was rust on the washing machine in the laundry area.
4. There was molded linen behind washing machine number 1 in the laundry area.
5. There was cross-contamination in handling of laundry.
6. The water temperatures were not monitored in laundry.
7. The chemical additives in laundry were not measured.
8. There was a hole in wall in the Dietary Department
9. There was water on the floor of the walk-in refrigerator.
10. Discolored ceiling tiles throughout the facility.
11. Chipped paint on doorways and in patient rooms throughout the facility.
12. Small holes in walls of patient rooms and bathroom throughout the facility.
13. Wooden cabinets and shelving unfinished throughout the facility.
14. Two portable suction machines with open Yankauer suction tips attached in open sleeves.

The failed practice promoted the spread of infection and had the likelihood to affect all patients in the facility. See C-1208 for details.

Based on observation, review of policy and procedure, and interview, it was determined the facility's Environmental Services department failed to use the established cleaning products for a terminal cleaning of discharge Room #119 with a Stryker bed. The failed practice promoted the spread of infection and had the likelihood to affect all patients. Findings follow:

A. Review of Policy and Procedure titled, "Cleaning Rooms with Stryker Beds," showed that Stryker beds were to be wiped down with Caviwipes only; sinks, faucets and showers were to be cleaned with liquid comet and rags; and cabinet and nightstand tables were to be wiped with wood polish and rags.
B. Observation on 6/13/23 at 2:30 P.M. showed Staff Member #1 used Clorox wipes to disinfect the Stryker bed, Staff Member #2 used Triple S disinfectant spray to clean the sinks, faucets, and showers and Staff Member #2 cleaned the cabinet and nightstand with Clorox wipes.
C. The findings in A and B were verified with the Director of Nursing and Housekeeping Supervisor on 06/13/2023 at 11:00 AM.

Based on observation and interview, it was determined the facility failed to maintain a sanitary environment in that:
1. There were holes in the wall and ceiling in the laundry area.
2. There were water leaks in laundry area.
3. There was rust on the washing machine in the laundry area.
4. There was molded linen behind washing machine number 1 in the laundry area.
5. There was cross-contamination in handling of laundry.
6. The water temperatures were not monitored in laundry.
7. The chemical additives in laundry were not measured.
8. There was a hole in wall in the Dietary Department
9. There was water on the floor of the walk-in refrigerator.
10. Discolored ceiling tiles throughout the facility.
11. Chipped paint on doorways and in patient rooms throughout the facility.
12. Small holes in walls of patient rooms and bathroom throughout the facility.
13. Wooden cabinets and shelving unfinished throughout the facility.
14. Two portable suction machines with open Yankauer suction tips attached in open sleeves.

The failed practice promoted the spread of infection and had the likelihood to affect all patients in the facility. Findings follow:

A. Observation of the Dietary Department on 06/12/23 at 2:45 PM showed the following:
1. There was a hole in the wall where the food carts were stationed.
2. There was water on the floor of the walk-in refrigerator.
B. The findings in A were confirmed by Dietary Supervisor on 06/12/23 at 2:45 PM.
C. Observation of the Laundry Department on 06/12/23 at 3:30 PM showed the following:
1. There were holes in the walls and ceiling behind washing machine one.
2. There were water leaks found near the washing machines.
3. There was rust on the washing machine.
4. There was a molded linen on the floor behind washing machine one.
5. There was cross-contamination in the handling of laundry. Observation of Environmental Services (EVS) Worker #1 on 6/12/23 at 3:35 PM showed EVS Worker #1 placed potentially contaminated laundry in the washing machine. EVS Worker #1 then removed clean laundry from the dryer and held the clean laundry against themselves potentially contaminating the clean laundry.
6. Review of the Auto Chlor Customer Service Reports dated from 03/03/23 to 05/26/23 showed there was no evidence the water temperatures were monitored to determine if the laundry was washed at the established temperature parameters per the ADH Rules for Hospitals and Related Institutions Table 9.
7. Review of the Auto Chlor Customer Service Reports dated from 03/03/23 to 05/26/23 showed there was no evidence the chemical additives were monitored to determine if the laundry was washed at the established parts per million per the ADH Rules for Hospitals and Related Institutions Table 9.
D. The findings in C were confirmed with Housekeeping Supervisor on 06/12/23 at 3:45 PM.
E. Observation of the Receiving Room on 06/13/23 at 3:20 PM showed the following:
1. There was a hole in the ceiling over the supply boxes.
2. The supplies were stored on wooden pallets which kept supplies to close the floor.
F. The findings in E were confirmed with Director of Nursing (DON) on 06/13/23 at 3:20 PM.
G. Observation of the Central Supply room on 06/13/23 at 12:45 PM showed the following:
1. Two portable suction machines with open Yankauer suction tips attached in open sleeves.
2. Unfinished wooden shelving used for storing supplies.
3. Shelving extended too low as to allow contamination during cleaning of the floors.
H. The findings in G were confirmed by DON on 06/13/23 at 1:00 PM.
I. Observation of the facility on 06/13/23 on tour from 12:30 to 2:20 PM showed the following:
1. Discolored ceiling tiles throughout the facility.
2. Chipped paint on doorways and in patient rooms throughout the facility.
3. Small holes in walls of patient rooms and bathroom throughout the facility
4. Wooden cabinets and shelving unfinished throughout the facility.
J. The findings in I were confirmed by DON at time of observation.

Based on review of contract and interview, it was determined the facility failed to have a current agreement with an eye bank, as required by CMS. By not having a current agreement, the facility could not ensure that individuals and families were given the opportunity to donate eye tissue, and that, when such a donation is offered, the parties can respond to the donation with compassion, professionalism and timeliness. The failed practice had the likelihood to affect all persons who pass away at the hospital and potential recipients. Findings follow:

A. Record review of "The Agreement Between The Arkansas Lions Eye Bank and Laboratory and DeWitt Hospital" showed the agreement ended August 31, 2010.
B. During an Interview on June 12, 2023, at 3:36 PM, the Director of Nursing verified the Agreement had expired.

Based on clinical record review and interview, it was determined the Facility's Interdisciplinary Team (IDT) failed to complete a plan of care (POC) and weekly reassessment after the initial assessment to update the POC for five of five (#1-#5) swing bed patients. The failed practice had the likelihood to effect continuity of care. The failed practice had the likelihood to affect all patients admitted to the Swing Bed unit. The findings follow:

A. During an interview on 06/13/23 at 10:30 AM, Patient Coordinator confirmed there was no evidence of policies for IDT to complete a POC.

B. Review of clinical record of Patient #1 on 06/13/23, admitted 05/31/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/13/23 at 1:30 PM, Patient Coordinator confirmed the findings in B 1-3.

C. Review of clinical record of Patient #2 on 06/13/23, admitted 06/01/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/13/23 at 1:40 PM, Patient Coordinator confirmed the findings in C 1-3.

D. Review of clinical record of Patient #3 on 06/13/23, admitted 04/06/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/13/23 at 1:50 PM, Patient Coordinator confirmed the findings in D 1-3.

E. Review of clinical record of Patient #4 on 06/13/23, admitted 05/04/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/13/23 at 2:00 PM, Patient Coordinator confirmed the findings in E 1-3.

F. Review of clinical record of Patient #5 on 06/13/23, admitted 01/18/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/13/23 at 2:15 PM, Patient Coordinator confirmed the findings in F 1-3.

Based on review of the Arkansas Rules and Regulations for Hospitals 2021, Section 21, review of Physical Therapy Staff personnel files, review of therapy sessions provided and interview, it was determined two of two (#1 and #2) Physical Therapy Staff were not qualified to provide services in that they did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification. By not having evidence of this qualification, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that received Physical Therapy Rehabilitation Services. Findings follow:

A. Record review of the Arkansas Rules and Regulations for Hospitals 2021, Section 21, showed all physical therapy personnel who participate in direct patient care shall be competent in life support measures.
B. Review of Physical Therapy Staff #1 and #2 files showed no evidence of a current CPR certification. Both previous CPR certifications expired 03/31/2023.
C. Review of a list of therapy sessions provided by Physical Therapy Staff with expired CPR showed the following:
1. Physical Therapy Staff #1 provided therapy on the following days in 2023:
March 6, 10, 14, 16, 20, 21, 28, 29
April 20, 24, 25
May 1, 2, 4, 8, 17, 19, 22, 30, 31
June 5, 6, 8, 12, 13
2. Physical Therapy Staff #2 provided therapy on the following days in 2023:
April 13, 18
May 30
D. During an interview on 06/13/2023 at 10:15 AM, the Director of Nursing verified that the Physical Therapy Staff #1 and #2's CPR certifications had expired 03/31/2023.